BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.7 of 2017

Date of Instt. 03.01.2017

Date of Decision: 17.10.2018

Mrs. Sosan wd/o Late Sh. Mohan Lal, R/o H. No.55, Indira Colony, Village Dhina, Jalandhar Cantt.

..........Complainant

Versus

1. SBI Life Insurance Company Ltd., State Bank of India, Air Force Station, Adampur, Distt. Jalandhar Through Branch Manager.

2. Head-Claims, SBI Life Insurance Company Ltd., Regd. Office “Natraj” M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai-400069.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Harvimal Dogra (Member)

Present: Sh. Shekhar Prabhakar, Adv Counsel for the Complainant.

Sh. Vikas Sharma, Adv Counsel for the OP No.1 and 2.

Order

Karnail Singh (President)

1. This complaint has been filed by the complainant, wherein alleged that the complainant is the widow and nominee of Late Sh. Mohan Lal deceased, who had been issued a policy bearing No.70000003903 namely SBI Rin Raksha Personal Loan Scheme against LAC No.34186081178 commenced from 28.09.2014 to 29.09.2018, from the branch of OP No.1. The sum assured in the policy was Rs.3,10,000/- and OPs also deducted premium of Rs.7326/- from the deceased Mohan Lal against the policy issued. That while issuing the said policy, the OPs had assured the deceased and his family members including complainant that sum assured would definitely be credited to the complainant in case of any mishappening occurs. On the assurance and being allured by the OPs, the deceased husband of complainant Sh. Mohan Lal took the policy from the OPs.

2. That unfortunately, on 07.10.2015 Sh. Mohan Lal deceased, policy holder had to be got admitted in Sacred Heart Hospital, but later on, he died in the hospital. The complainant was very shocked after the sad demise of her husband i.e. policy holder Sh.Mohan Lal. Thereafter, the complainant being nominee of the policy holder applied claim of sum assured of Rs.3,10,000/- before the OPs, which was repudiated by the OPs, vide their order dated 11.02.2016 on false and frivolous grounds. The facts and circumstances submitted in the complaint prima facie proves that there is serious deficiency on the part of the OPs in rendering proper services to the complainant and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the insured amount of Rs.3,10,000/- to the complainant along with litigation expenses of Rs.20,000/- and compensation for harassment and mental agony, caused to the complainant to the tune of Rs.1,00,000/-.

3. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the instant complaint is not maintainable for want of territorial jurisdiction and further submitted that the life insurance contract is a contract of Utmost Good Faith, wherein the proponent is duty bound to disclose everything concerning his/her health, habits and other related matters, which are within his/her knowledge at the time of making the proposal for insurance cover and even before the date of commencement of the policy, failing which the insurer has every right to repudiate the claim. In the instant case, the deceased life assured Mohan Lal committed a breach of the principle of Utmost Good Faith by suppressing the material fact that the deceased life assured was suffering from Chronic Obstructive Pulmonary Disease with Pneumonia prior to the date of submission of the proposal form and accordingly, the insurance claim of the complainant has been rightly repudiated. On merits, the factum in regard to purchase of the policy by deceased Mohan Lal is admitted and it is also admitted that the claim of the complainant has been repudiated, vide letter dated 11.02.2016, but the remaining allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

4. In order to prove the case of the complainant, the complainant herself tendered into evidence her own affidavit Ex.CA along with some documents Ex.C-1 to Ex.C-6 and then closed the evidence.

5. Similarly, counsel for the OPs tendered into evidence affidavit Ex.OP/A along with some documents Ex.OP/1 to Ex.OP/37 and closed the evidence.

6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

7. Precisely, we discuss the facts of the case in hand, whereby the complainant asked for insurance claim of her husband Mohan Lal, to the tune of Rs.3,10,000/- with interest, compensation and litigation expenses and further alleged that the said insurance claim has been wrongly repudiated by the OP, vide letter dated 11.02.2016.

8. On the other hand, the OP took a simple plea that this Forum has no jurisdiction to entertain the present complaint for want of territorial jurisdiction and further submitted that the deceased life assured concealed the material facts from the insurance company, by suppressing previous disease of Chronic Obstructive Pulmonary Disease with Pneumonia prior to inception of the policy and alleged that the insurance claim of the complainant has been rightly repudiated.

9. We have considered the above submission of both the parties and find that the OP has brought on the file copy of Membership Form Ex.OP/7 filled by the deceased life assured at the time of inception of the policy and the said form is duly signed by the insured Mohan Lal, wherein he disclosed that he was not having any disease at the time of inception of the policy or prior to that and he never remained admitted in any hospital, but later on, after the death of the insured Mohan Lal, matter was got investigated from the Investigator, whose report is produced on the file by the OP Ex.OP-11, wherein the said Investigator categorically gave opinion that the deceased insured Mohan Lal remained admitted in the hospital from 14.05.2014 to 27.05.2014 with diagnosis of COPD and Pancreatitis. He remained under OPD treatment since then as per documents obtained. He lastly admitted on 07.10.2015 and while at the hospital expired at 10.20 PM and further OP, in order to prove that the deceased insured was having a disease prior to inception of the policy, the OP has brought on the file discharge record of the Sacred Heart Hospital, Maqsudan, photostat copy of the same is Ex.OP/16, which shows that the deceased Mohan Lal remained admitted in the hospital from 14.05.2014 to 20.05.2014 and history of the problem mentioned as Breathless 3 months. Alongwith this discharge slip, the OP has also brought on the file treatment slips Ex.OP/13 to Ex.OP/27 and further proved on the file a certificate of hospital treatment, which shows that the deceased Mohan Lal remained admitted in the hospital on 07.10.2015 and died on the same day and even the OP has also produced on the file photostat copy of the application for leave from the department, where deceased insured Mohan Lal was working and the said application is Ex.OP/32, which shows that the deceased Mohan Lal was on medical leave from 19.05.2014 to 30.05.2014 and on the basis these medical documents and report of Investigator, the OP has repudiated the claim of the complainant on the ground that the deceased insured had pre-existing disease, which is not fit within the parameter of the term and condition of the insurance policy.

10. We have considered all the documents produced by the complainant as well as OP very sympathetically and find that the insurance policy of the deceased Mohan Lal was for the period 28.09.2014 to 29.09.2018 and as per record, the deceased Mohan Lal remained admitted in the hospital from 14.05.2014 to 27.05.2014 and the reason for admission is only breathless for 3 months, we find simply admission in the hospital for want of breathless for 3 months is not a critical disease rather it is a routine problem, which can arise to any person and it cannot be considered as serious or critical disease and moreover, in this discharge slip on the second page Ex.OP/17, the doctor has categorically mentioned that the patient is treated and patient is fit to be now discharged. The aforesaid wording of the doctor itself shows that the disease to the deceased Mohan Lal was a curable and same is cured within 4 to 5 days and thus, this document is not going in favour of the OP in any manner and moreover, the report of the Investigator Ex.OP-11 is also based on this discharge slip, therefore, the report of the investigator is also having no value in the eyes of law because the investigation is not itself independent rather depends upon the discharge slip issued by the Sacred Heart Hospital. So, for the second time admission of the deceased Mohan Lal in the hospital is related, the same is only for one day and on the same day, he was died in the hospital, which is very well explained in the certificate of hospital treatment Ex.OP-28, so, this certificate cannot be considered as pre-existing disease to the insured.

11. Further, the leave application Ex.OP/32 does not have any significant to prove that there was any pre-existing disease to the complainant because if simple sickness came to the person, then he must get a leave, but we cannot consider that the disease of sickness as a critical disease. So, from all angle, we are of the opinion that the document produced on the file in regard to treatment of the deceased insured Mohan Lal does not give any strength to the version of the OP that there was any pre-existing disease to the deceased insured Mohan Lal and in support of our above observation, we like to refer a judgment of the Hon'ble National Commission, cited in 2014(3) C.P.J. 552, titled as “SBI Life Insurance Co. Ltd. Vs. Harivinder Kaur and another”, an other judgment of the Hon'ble National Commission, cited in 2006(4) C.P.J. 189, titled as “Praveen Damani Vs. Oriental Insurance Co. Ltd.” and an other judgment of the Hon'ble State Commission, cited in 2010(2) C.P.R. 342, titled as “Life Insurance Corporation of India Vs. Hukum Devi”.

12. In the light of above detailed discussion, we are of the opinion that the claim of the complainant has been wrongly repudiated by the OPs and as such, we came to conclusion that the complainant is entitled for the relief claimed and thus, the complaint of the complainant is partly accepted and OPs are directed to pay insured claim amount of Rs.3,10,000/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim i.e. 11.02.2016, till its realization and further OPs are directed to pay compensation to the complainant for mental harassment and agony, to the tune of Rs.25,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Harvimal Dogra Karnail Singh

17.10.2018 Member President